Another
Inside Healthcare Computing Scoop Comes To Pass:HIMSS Buying Dorenfest for
$6 Million

As we had predicted months ago (Inside Healthcare Computing,
2/23/04), the Healthcare Information and Management Systems
Society (HIMSS) has signed to acquire the Dorenfest Database. The
price was $6 million, said HIMSS spokeswoman Joyce Lofstrom.

The database will be a foundation
for a new subsidiary that will offer market research to healthcare
organizations. Also as we'd predicted, David E. Garets, formerly
of Gartner Group, is president and CEO of the new service, which
will be called "HIMSS Analytics."

McKesson,
Siemens, Eclipsys All On The Standard Cerner Rebuked
For Lagging On Arden Syntax

The co-chair of the HL7 Committee
on Arden Syntax says Cerner Corp. has not implemented a standard
version of Arden Syntax in its products.

"It is an area of concern,"
said R. Matthew Sailors, an adjunct assistant professor in the
department of health informatics at the University of Texas
Houston Health Sciences Center.

Arden Syntax is used to encode
medical knowledge. It is used in medical decision-making and
decision support rules. Dosing recommendations, clinical
protocols, and contra-indications are all examples of data that
can be configured according to Arden Syntax.

Old version can't share
decision rules

Dr. Sailors said Cerner
implemented a non-standard version years ago, and has stuck with
it ever since. As a consequence, physicians from Cerner sites will
find it difficult to share decision support rules with others.
Siemens, McKesson, and Eclipsys all use standard versions, he
said.

Dr. Sailors said he has tried and
failed to get a clear answer on Cerner's plan for getting current
on the standard syntax.

Since he said he couldn't get an
answer, we contacted Cerner about his concern, first on May 24,
2004. On June 3, we e-mailed our questions. This is a slightly
edited version of what we asked:

MDs Debate What Belongs On
Patient Wristbands

Questions about what belongs on a
patient wristband are heating up, as more hospitals redesign their
wristbands to accommodate bar code readers.

In many systems, the encoded
number is the data element that retrieves the record from the
electronic system. Many organizations encode just the medical
record number. However some MDs, posting comments on a chat board
recently, pointed out that the medical record number does not
expire but an encounter number can. That could be useful for
identifying patients who no longer belong in the hospital.

The encounter number could serve
a second purpose. JCAHO requires two patient identifiers. Nothing
says that one can't be bar-code-readable and the other
human-readable, wrote Steven J. Davidson, MD, chair of the ER
department at Maimonides Medical Center, New York City.

The human-readable part be a
cross-check on the machine-readable portion.

However, if mishandled, it can
pose patient security concerns. Most MDs seem uncomfortable about
the thought of putting patient social security number or mothers'
maiden names on the wristband.

There are other issues as well.
The longer the barcode, the longer the string of wireless data you
send. In some systems, that might degrade system performance.
Also, there's only so much data you can cram on a wristband and
still leave enough room for a barcode. For example: should the
hospital's name go on the wristband?

Seeking quick answers, we
contacted Bridge Medical, a leader in bar-coded medication system
sales. Bridge requires that patient record numbers be encoded, and
says the rest is pretty much up to the organization. Most new
Bridge clients continue doing whatever they did before, said Mike
Issac, VP customer service.

Here's what MDs said:

Patricia L. Hale, MD, who is
CMIO at Glens Falls, N.Y., Hospital: the hospital barcodes the
medical record number. The human-readable portion is patient name,
date of birth and gender.

She added that she welcomes
suggestions from other organizations which are further down the
road.

Other information that may be
useful: an indicator of patient status (inpatient/outpatient) and
the name of the institution. "The answer, of course, depends
on how much storage space you have in the bar code." He notes
that a two-dimensional barcode reader is useful in that regard.

Jonathan Silverstein, MD,
director for clinical
information, University of Chicago:

Encoded information -- Medical
record number, gender, date of birth. Human-readable
information--name, medical record number, gender and date of
birth. "Patients should be encouraged to check their own
information," he said. (Dr. Silverstein warns that his
opinions are based on "no data.")

Dr. Davidson: Maimonides prints
bar-coded wrist bands only in Emergency. Hospital name, patient
number, medical record number, date of birth, date of service, and
encounter number are written in text. Only the medical record
number is coded.

Nobody asked our opinion, but
here's a question: why not make wristbands bigger?

Centura Created Its Own
Approach To Clinical Systems Selection

(Editor's note: in our last
issue, we told how three-hospital Community Foundation of
Northwest Indiana used an alternative to the standard RFP approach
for the difficult task of selecting the right information system.
Here's another alternative.)

Colorado's biggest health system,
11-hospital Centura Health, Englewood, is close to announcing some
big news: its contract for a new suite of clinical systems.

While vendor finalists squirm
over who will win the deal, a question that can be now answered is
"How" what it takes to get to a sensible decision on a
system that every caregiver has to use, and which will live or die
on the basis of clinician support.

Here's how Centura has gone about
it, starting 2-1/2 years ago, according to Karen Romero, VP
clinical technology (We took in her recent HIMSS teleconference
and interviewed her afterward.).

Centura used a meticulous process
that included careful development of organizational visions and
before-the-fact changes in work processes. You won't find this
approach at any consulting web sites because Centura created it.

Centura pulled 25 clinical
leaders into a two-day retreat, and studied "business drivers"
that affect clinical operations. With business needs in mind, they
agreed on a brief statement of their clinical vision. That led to
a clinical information technology vision. Then they did detailed
needs assessments. They analyzed and developed revisions to work
processes. They identified key goals for bringing work processes
in line with the clinical vision.

Does this sound esoteric -- and
possibly like a big waste of time -- to you? It did Centura
clinicians, too: many asked "Can't we just go pick a system
and put it in?"

(Editor's note: again we see a
lesson illustrated by a failure elsewhere. This seems simple in
hindsight: you need to focus on clinicians' work processes.
Howeve, it's a struggle to get them to tell you.

We'd had reported before that
computerized physician order entry, the core of a new in-house
clinical information system at Cedars Sinai Medical Center, worked
as technology, but interfered with work processes, whichwas blamed
as a key reason MDs rebelled against it.

Management at Cedars was not
unaware of work flow. It had tried to get non-IT-oriented
physicians involved in development but wasn't successful, probably
because Cedars doesn't pay MDs for committee work, and MDs who
want to focus on beating diseases didn't want to be on a boring
clinical IT committee.)

Because the Centura process began
with, "What are our business drivers?", it built
organizational energy and trickled down into some fairly detailed
needs assessments that helped prevent MDs from "losing focus"
in the face of vendor demos.

(She didn't say exactly what "business
drivers" means, but from the context, it seems evident:
everything that affects whether you and MDs make money, and how
much--including, of course, quality of clinical results: nothing
drives away patient business faster than the perception that the
hospital is a mistake-prone menace to life and limb.)

A few approaches that worked well
for Centura::

Organization-wide buy-in.
How do you know whether you have achieved it? Ms. Romano offers
this useful measure: is the organization willing to take key
clinicians away from treating patients during working hours, or
else pay them extra, so that they can participate in system
design?

A modular implementation
approach. Break your project down into "repeatable
initiatives" such as bringing one nursing unit live on your
system. At each step, measure your results. If they are good,
publicize them widely, if they are poor, share them with your
steering committee, so they can be used to fix problems and make
subsequent roll-outs go smoothly.

Accept "Good, not
perfect." For most hospitals, making a systems rollout
work well, but moving on to the next one before it is perfect,
is a tough but necessary adjustment.

Centura dealt extensively with
analysis of organizational workflow -- a term so tossed around
that it's become room noise in a lot of presentations. Ms. Romano
says the term has these three distinct meanings:

1. The series of steps it takes
to get a patient admitted, treated and discharged.

In a pre-implementation exercise,
Centura entirely re-designed its meds administration workflow to
remove unneeded "moving parts," then began standardizing
all its hospitals on the new way to do things. This was done with
completely manual systems, but having workflow freshly redesigned
first has helped clinicians to know exactly what they will need
from their information systems.

2. Workflow is also the series of
screens within a vendor product that approximates the order in
which things are actually accomplished in a hospital.

3. Finally, workflow is the thing
embedded in a "workflow engine" which brings together
elements within a system to manage the life cycle of a process,
from definition through deployment, execution, and measurement.

Some vendors, such as Siemens,
are incorporating the capabilites of industry-standard workflow
engines in new systems that they are building from the ground up.
Others are modifying existing applications to give them
workflow-like capabilities, she said. It remains to be seen which
approach better serves healthcare IT.

Misys Takes An EC7000 (TDS)
Client Away From Eclipsys

How did a relatively unsung
vendor like Misys earn second place for inpatient clinical systems
in the recent TEPR meeting? It didn't surprise Joe Palombit.

In fact, as CIO of Pascack Valley
Hospital, 291 beds, Westwood, N.J., he'd probably tell you that
Misys should have been first. His shop is leaving an older
Eclipsys system for Misys.

Pascack Valley's selection
process was the traditional approach in most ways: a selection
team with subcommittees, RFPs, demos, and site visits. The
winnowing and selection were done by vote. Selection committees
from Pascack studied options for two years before concluding that,
for most of its users, a Per Se (now Misys) system was head and
shoulders above the competition. The selection process was
prolonged because Per-Se sold its Patient1 suite to Misys, which
markets it as Misys CPR and Misys CPOE.

If Misys clinicals are so
all-fired great, then why are so many organizations licensing
Cerner and Eclipsys?

"We kept asking
ourselves the same question," he said. His best guess:
the system has been around for a long while and it is not widely
installed, so people assume there is something amiss with it. "It's
like the
world's best programmer who can't
get a job because he's never had one." Also, in his opinion,
it is not well marketed. "They have a very weak sales force."

Pascack 's plan to upgrade was
driven mainly by a need for better systems integration and a
desire to address medication errors with decision support without
giving up too much on the response times users had with Eclipsys
(formerly TDS).

Misys can match EC7000 on
response time, but Pascack's plan to add decision support is
likely to slow it down, he said. Pascack saw "acceptable"
system performance on a site visit to Arnot-Ogden, which uses both
off-the-shelf and customized decision support. Pascack already
enjoys 40% physician order entry. With Misys, the target is 100%.

From RFP design, to demo and site
visit protocols, through the final contract, Pascack was advised
by Kurt Salmon & Associates. Project head was longtime HIS
consultant Elaine Remmlinger. Mr. Palombit speaks of the firm with
a warmth and respect that is rare between CIOs and consulting
firms. "I cannot tell you how much help they have been."

The RFP drew seven responses,
which were whittled down to these five by the steering committee:
Cerner, Eclipsys, Per-Se (now Misys), IDX, and Meditech.

Pascack invited each vendor to
hold two simultaneous day-long series of one-hour demos. The idea
was to give each user task force and the steering committee a
chance to evaluate the products on their own terms and
convenience.

For example MD demos were
scheduled for 7 a.m. and noon. Everyone was welcome, even if they
could only stay for 20 minutes, he said. The only rule was that if
you showed up, you had to vote. The net of it: "We involved
actual hands-on end users " in the selection process.

A second round of demos was a
clinicians-only affair. MDs and nurses were invited to sit down at
PCs and test the systems with dummy orders. Only about 15
participated, but the group did include some of Pascack's heaviest
admitters.

Meditech: Pascack
financial people favored it because it has an all-integrated
platform. That was a big plus because Pascack has had difficulty with information drops across
the E-Link interface engine to Cerner lab and, especially Cerner
pharmacy. However, the medical staff, accustomed to the
flexibility of EC7000, found Meditech too rigid.

IDX came in third with
MDs and nursing, but was popular with ancillary departments.
Also, IDX prices seemed high to Pascack.

Cerner didn't do well
in the final tally with Pascack, despite the fact that it runs
Cerner Classic Lab and Parmacy, and lab representatives on the
Pascack ancillary team initially strongly favored Cerner. Cerner
and IDX were "very close" on clinician ratings,
However, Cerner didn't do well on Pascack's reference checks.
Cerner has financials live, but at only a couple of sites.

Tips to boost dollar-value
of site visits

Site visits followed. Here are
two things Pascack to make the trips worth the money:

It made them less expensive,
saving on air fares by piling key selection team members into
cars and driving. (The drive to Arnot-Ogen, in Elmira, N.Y.,
just 245 or so freeway miles away, is probably also faster by
car, given today's airport security delays.)

It barred vendor sales people
from attending. Salesmen met Pascack teams at each site, made
introductions, and then cleared out, and didn't return until 2
p.m. Each site was asked to prepare a 45-minute PowerPoint
presentation that introduced the site and gave the basics of the
implementation. Team members then peeled off for sessions with
their hospital counterparts. A nurse could walk up to a person
putting in an order and ask "how do you find the system?"
Everybody lunched together.

Medication Errors As A
Rationale For CPOE: IT Execs, MDs Fire Back

On May 23, we sent an e-mail to
non-subscribers (and possibly some readers) offering access to a
copy of a commentary, "Before Your Organization Spends
Millions On CPOE ... An Analysis Of the Medication Errors Numbers"

This commentary argues that based
on reported medication error rates and their sources, the goal of
reducing medication errors, by itself, can't come close to
cost-justifying the expense of a CPOE system. (It does
acknowledge, of course, that there are other reasons for CPOE.)

The commentary is an updated and
rewritten version of one we sent by e-mail to electronic
subscribers late last year. We invited these visitors to respond,
either for attribution or otherwise.

To date, over 1,000 people have
read that commentary (or at least loaded it into their browsers),
making it the most widely read page in a few-days span ever at our
web site.

The most common response has been
the somewhat-less-than-gratifying "Remove me from your
mailing list," which we attribute to that utterly human
desire not to be confused by the facts.

However, several readers of the
commentary did take the time to write thoughtful responses, about
half agreeing, half disagreeing. We think these responses are
useful, and we plan to publish them in an upcoming issue as part
of our ongoing coverage of clinical information systems.

What EMR Vendors Are
Charging

Most big HIS vendors strangely
guard their contract prices as if they were the secret rules for
torturing CIOs.

That's not the case for
electronic medical record systems for MDs. For at least the
smaller systems, prices of many electronic medical record systems
are available with a small amount of digging on vendor web sites,
in chat groups, and in published reports.

In general, the biggest vendors,
like HIS vendors, don't disclose their EMR prices. Epic and Misys
are the exceptions. But knowing what the competition charges can
give you an edge at the negotiating table.

These prices come from multiple
vendors through Mark Anderson, healthcare IT futurist and
principal of the AC Group, Texas. They are a small slice of Mr.
Anderson's comprehensive annual evaluation EMR systems and
vendors. They are all-inclusive and provide for hardware, database
servers, networking, training and implementation, annual support
fees, and a number of smaller installation considerations. Prices are per MD:

Participating vendors completed a
5,155-item functionality questionnaire in four areas: desktop
capability, wireless capability, remote access capability and PDA
and mobile capability. He then independently verified performance
of systems that ranked in the top ten in self-reported
functionality.

Epic: high price, middle on
functionality

A few observations:

When it comes to EMR
functionality, you don't necessarily get what you pay for. Epic
Systems, one of the higher priced options, ranks seventh in
functionality. Third-ranked SynaMed is among the lowest-priced.
On the other hand, as a group, EMR vendors are notoriously
unstable, and Epic seems pretty clearly here to stay.

In 2002, 2003 and 2004, NextGen
and AllScripts ranked in the top three in functionality. Both
are available for large practices.

In 2003, half a dozen vendors
announced plans to significantly improve functionality, as
measured by Mr. Anderson's scoring system. Only one, Greenway,
actually met or exceeded its own predictions. Greenway predicted
a modest 5% increase in functionality scores and actually
achieved a 6.5% increase. Two others came close. JMJ made big
strides that fell just short of what it had predicted: its 37%
increase in functionality missed its mark by only 2.7%.
Cliniflow promised a 24% improvement and achieved 20%.
MDAnywhere and eMDS also predicted significant improvement, but
elected against participating in the 2004 study.

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